Improving population health in Germany – lessons of a pilot study to assess health system performance

Abstract Background Improving the population health, both its level and equity, is a major goal of health systems. Health System Performance Assessment (HSPA) is a tool to evaluate the performance of different health system dimensions, e.g., population health, access, efficiency. For the first time, a systematic HSPA was piloted for Germany including the dimension population health. Methods The conceptual framework for the German HSPA pilot has been developed in a previous feasibility study. The selection of indicators was based on established indicators used in other HSPA initiatives. Another inclusion criterium was data availability. The ten indicators to measure population health cover e.g., maternal and neonatal health, amenable mortality, infectious diseases, and cancer screening. The indicators are evaluated in terms of their trend over time (2000-2020), in international comparison (e.g., Austria, Denmark, France), and by various equity criteria (e.g., age, gender, region). Results Overall, Germany's health system performs moderately regarding population health, especially when compared to selected European countries. While Germany performs very well in terms of incidence rates of infectious diseases, amenable mortality is an area with need for improvements. However, trends over time show improvements of the population health in Germany. Conclusions Measuring population health in Germany using ten predefined indicators reveals areas for improvement. Furthermore, subgroup analyses indicate inequities. These results should be considered in further efforts aiming at the improvement of population health in Germany. Key messages Population health in Germany has improved over time. However, measuring population health within the German health system identified needs for improvement and inequities.


Introduction:
Frequent users of emergency departments (FUED; 5 ED visits in the previous 12 months) often present with somatic, psychological and substance use problems. Providing a Case Management (CM) intervention may reduce their number ED visits and improve their quality of life. However, there is limited knowledge about the implementation process of CM.

Methods:
This study aimed to introduce CM into the EDs in the French-speaking part of Switzerland and to identify the facilitators, barriers and needs encountered in this process.
Semi-structured interviews were conducted with ED involved staff. An inductive content analysis was conducted. Results: Among 13 invited hospitals, 8 implemented CM (62%); 23 ED staff were sampled from all participating ED: 17 nurses (74%), 5 physicians (22%) and 1 healthcare manager (4%). The average age was 48,48 years (SD = 8,64) and 74% were female. Four main facilitators emerged from the analysis: 1) Direct hierarchy support and flexibility (e.g. time management, supplemental paid hours); 2) Exchange with colleagues (e.g. debriefing, support); 3) Supervision by the research team (training and toolkit consisting of a binder and USB stick containing the study presentation and implementation procedures); and 4) Motivation (pleasure to work on an innovative project, benefit for patients and caregivers). Lack of resources was an unanimously mentioned barrier (e. g., time to identify and contact FUED medical and social support). Finally, participants identified the following needs to enable CM implementation: official and protected time for the project, a dedicated room for CM, at least two team members involved in the project since its initiation with complementary skills (e.g.: somatic, psychiatric and social).

Conclusions:
Our study suggests that successful CM implementation is a complex process that, in addition to motivated ED staff, requires significant dedicated resources, such as protected time and a devoted support team.

Key messages:
Future research should establish a case management intervention with resources (time, space, teams with complementary skills) specifically dedicated to this process. In order to increase the quality of care, institutions should dedicate more funding for the implementation and sustainability of case management to enable its optimal application by caregivers.
Abstract citation ID: ckac130.010 Improving population health in Germany -lessons of a pilot study to assess health system performance

Background:
Improving the population health, both its level and equity, is a major goal of health systems. Health System Performance Assessment (HSPA) is a tool to evaluate the performance of different health system dimensions, e.g., population health, access, efficiency. For the first time, a systematic HSPA was piloted for Germany including the dimension population health.

Methods:
The conceptual framework for the German HSPA pilot has been developed in a previous feasibility study. The selection of indicators was based on established indicators used in other HSPA initiatives. Another inclusion criterium was data availability. The ten indicators to measure population health cover e.g., maternal and neonatal health, amenable mortality, infectious diseases, and cancer screening. The indicators are evaluated in terms of their trend over time , in international comparison (e.g., Austria, Denmark, France), and by various equity criteria (e.g., age, gender, region).

Results:
Overall, Germany's health system performs moderately regarding population health, especially when compared to selected European countries. While Germany performs very well in terms of incidence rates of infectious diseases, amenable mortality is an area with need for improvements. However,

Background:
The SARS-CoV-2 pandemic put under pressure all the world's health systems, to the point that it was a severe threat to their stability. At the same time, this scenario confirmed the importance of primary health care to guarantee effective care for patients who suffer from complex and chronic diseases. From these considerations and in the light of the funding provided by the European Union for enhancing the health care system in Italy, our working group has decided to analyse various organisational models of Primary Health Care founded around the world to set up innovative Primary care community Centers in Italy, called Community Houses.

Methods:
A scoping review of the international literature was conducted on Pubmed, searching for primary care models based on integration and co-location of services. Each organisational model was then evaluated using different levels of multidimensional integration inspired by the taxonomy work of P. P. Valentijn, such as clinical, professional, organisational, system, functional and normative integration levels.

Results:
The search produced 2053 results, initially screened by title and abstract and, subsequently, by full-text, finally obtaining 116 articles. When a model is characterised by integrating services with external stakeholders, it also presents more integration levels than the others. In particular, these models are, on average, about 20% more likely to have an organisational, functional and normative integration in the model. Moreover, by stratifying for population complexity, we can find an increase in integration levels for populations suffering from chronic diseases with a higher degree of complexity, such as diabetes or cancer.

Conclusions:
From these preliminary results, we can conclude that it is necessary to prefer primary care models with more integration levels to deliver better healthcare for people with complex or chronic diseases, improving the performance of the Health Care System, especially in Italy.

Key messages:
Our work has allowed us to advise the policymakers on a correct reorganisation of the National Health System in Italy employing the European Union funds. The results of this study will be used to organised Primary care community Centers in Italy, called Community Houses, which aim to facilitate the integration and co-location of services.

Methods:
A cross-sectional survey is conducted in Israel among 491 primary caregivers of deceased cancer patients, Jewish and Arab, in three oncology centers.

Results:
About 43% caregivers said that they and/or the patients had paid OOP for medications during the last half-year of the patient's life. Most (73%) oncologists who suggested an OOP medication hardly asked or did not ask about financial ability and took little or no interest in ability to afford it, 43% hardly explained or did not explain the advantages of an OOP medication, and 52% hardly explained or did not explain any treatment alternatives. A linear regression analysis reveals that older age and female gender are related to less communication about an OOP medication and that better education, greater affluence, and having private health insurance are related to more communication. About 56% of caregivers say that OOP payment for medications inflicted a very heavy or heavy financial burden on patients and their households. A regression analysis revealed that physicians' interest in their financial ability and in the explanation they gave decreased their burden.

Conclusions:
Discussing and explaining the meaning of OOP payment alleviates the financial burden that families experience. It is crucial to develop and invest in improving oncologists' education and skills to communicate costs more openly. Key messages: Few oncologists took much interest in patients' ability to afford medications, while most caregivers found OOP payment for medications burdensome.
Oncologists' explanations and interest in patients' means lightened the burden. Oncologists need to be better educated in speaking about costs.